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In 2006, CDC recommended human immunodeficiency virus (HIV) testing for adults, adolescents, and pregnant women in health-care settings and HIV testing at least annually for persons at high risk for HIV infection* to foster early detection, facilitate linkage to care, and improve health outcomes (1). Understanding previous HIV testing patterns among persons recently diagnosed with HIV infection can help in the design of HIV testing strategies that reduce the time between onset of HIV infection and its diagnosis. To assess previous HIV testing patterns among adults and adolescents newly diagnosed with HIV infection, CDC analyzed data for the period 2006–2009 from 18 jurisdictions participating in HIV incidence surveillance through CDC's National HIV Surveillance System (NHSS) (2).† This report describes the results of that analysis, which indicated that among adults and adolescents for whom testing history information (THI) was available, 41% were diagnosed with HIV infection at their first HIV test, and 59% had a negative test at some point before HIV diagnosis. Groups with the highest percentage of persons testing HIV-negative ≤12 months before HIV diagnosis included those aged 13–29 years (33%), males with HIV transmission attributed to male-to-male sexual contact (29%), and whites (28%). These results demonstrate that many persons diagnosed with HIV infection have never been tested previously. Persons who are unaware of their HIV infection might not change their behavior to reduce the risk for transmission and will not be linked to care, resulting in worse health outcomes. Enhanced efforts are needed to increase annual HIV testing for populations at high risk for HIV infection to increase early detection.

The analysis included persons aged ≥13 years with a new diagnosis of HIV infection during the period 2006–2009 (reported to CDC through June 2010) from 18 jurisdictions participating in HIV incidence surveillance through NHSS (2). THI§ collected for the purposes of HIV incidence surveillance and reported to CDC through January 2011 was used to determine whether persons diagnosed with HIV infection ever had a previous negative HIV test and to calculate the time from their most recent negative HIV test to HIV diagnosis (2). The number of diagnoses was adjusted for reporting delay but not for incomplete reporting. Multiple imputation was used to assign a transmission category to those cases for which risk information was not reported (3,4).

An estimated total of 125,104 persons aged ≥13 years were newly diagnosed with HIV infection during 2006–2009; THI was available for 57,476 (46%). Compared with persons for whom THI was unavailable, a higher percentage of those with THI were persons aged 13–29 years (37.8% versus 24.8%) or males with HIV transmission attributed to male-to-male sexual contact (men who have sex with men [MSM]) (73.9% versus 68.5%), and a lower percentage were persons aged 40–49 years (23.0% versus 29.5%) or aged ≥50 years (13.4% versus 19.8%). Among persons for whom THI was available, 59% (34,049) were reported as ever having a negative HIV test before HIV diagnosis, and of these, 32,752 (96%) had data available to calculate the time from their most recent negative HIV test to HIV diagnosis. The highest percentages of persons with a previous negative HIV test were observed among whites (9,846 [67%]), persons aged 13–29 years (14,220 [65%]), and males whose HIV transmission category was MSM (20,317 [65%]) or MSM/injection drug use (IDU) (1,151 [65%]) (Table 1).

Among the 57,476 persons newly diagnosed with HIV infection for whom THI was available, 13,900 (24%) had a negative HIV test ≤12 months before HIV diagnosis, 6,758 (12%) had a negative HIV test 13–24 months before HIV diagnosis, 12,094 (21%) had a negative HIV test >24 months before HIV diagnosis, 1,297 (2%) were missing data to calculate the time since their last negative HIV test to HIV diagnosis, and 23,427 (41%) had HIV diagnosed on their first test. The groups with the highest percentage of persons testing HIV-negative ≤12 months before HIV diagnosis were persons aged 13–29 years (7,122 [33%]), whites (4,112 [28%]), and males in the MSM transmission category (9,620 [29%]). The groups with the highest percentage of persons with no previous negative HIV test included those aged ≥50 years (4,492 [59%]), males in the heterosexual contact¶ (3,476 [56%]) or IDU (1,674 [54%]) transmission categories, blacks/African Americans (13,188 [44%]), and females in the heterosexual contact transmission category (5,451 [44%]) (Table 2).

A higher percentage of persons diagnosed with HIV on their first test had acquired immunodeficiency syndrome (AIDS) within 6 months of HIV diagnosis compared with those who had a previous negative HIV test (37% versus 20%). No significant changes from 2006 to 2009 were observed in any stratum in the percentages of persons with a previous negative HIV test.

Editorial Note

The findings in this report show that the majority (59%) of the adults and adolescents diagnosed with HIV infection during 2006–2009 in the 18 jurisdictions included in the analysis had a negative HIV test before diagnosis; only 24% had a negative test ≤12 months before HIV diagnosis, with higher percentages observed among young persons and MSM. Previous reports have shown increasing numbers of new HIV infections among young persons and MSM; the findings in this report might reflect enhanced testing efforts directed toward these groups (2,5).

The findings also show a high percentage of persons diagnosed with HIV infection with no previous HIV test, particularly those aged ≥50 years, blacks/African Americans, and persons whose HIV transmission is attributed to heterosexual contact or IDU. HIV surveillance data show a higher prevalence of AIDS diagnosed within 12 months after HIV diagnosis among injection drug users and persons aged ≥50 years (6), indicating that these groups tend to be diagnosed later in the course of HIV disease than other groups. Additionally, persons diagnosed with HIV infection on their first test are more likely to be diagnosed later in the course of HIV infection. Emphasis on HIV screening in health-care settings and annual testing for persons at high risk would help increase the proportion of HIV-infected persons who benefit from early diagnosis.

The findings in this report are subject to at least three limitations. First, results are based on data from 18 jurisdictions, which accounted for approximately 60% of reported AIDS cases in the United States during 2006–2009, and therefore are not generalizable to the entire U.S. population. Second, less than half of the estimated number of persons diagnosed with HIV infection had THI available. Although younger persons and MSM were more likely to have THI available, the extent to which this difference might have affected the findings is unknown. Finally, adjustment for reporting delays and missing risk factor information might have introduced uncertainties into estimates of HIV diagnoses.

The National HIV/AIDS Strategy calls for expanded efforts to prevent HIV infection using a combination of effective, evidence-based approaches (7) and for intensified HIV prevention efforts in the communities where HIV is most heavily concentrated (e.g., among blacks/African Americans, Hispanics/Latinos, gay and bisexual men, and substance abusers). Accordingly, the strategic plan of CDC's Division of HIV/AIDS Prevention aims to increase the percentage of persons living with HIV who know their serostatus and who are diagnosed with HIV infection at earlier stages of disease by supporting and strengthening HIV testing in these communities (8). As part of CDC's continued support for HIV testing, CDC has launched a new 5-year funding opportunity for health departments in states, territories, and selected cities to reduce HIV transmission by better targeting resources and supporting the highest-impact prevention strategies to increase HIV testing and access to care, improve health outcomes, and increase awareness by educating communities about the threat of HIV infection. Other strategies include the Act Against AIDS campaign, which is a 5-year national campaign launched in 2009 by CDC and the White House that focuses on raising HIV/AIDS awareness among all persons in the United States and reducing the risk for infection among the hardest-hit populations, including gay and bisexual men, blacks/African Americans, Hispanics/Latinos, and other communities at increased risk. The findings in this report provide insight into HIV testing patterns among persons diagnosed with HIV infection in the United States and underscore the need to enhance efforts to increase annual HIV testing for populations at high risk for HIV infection and to reduce the percentage of persons being diagnosed with HIV on their first test, particularly blacks/African Americans and injection drug users.

* Persons likely to be at high risk include injection-drug users and their sex partners, persons who exchange sex for money or drugs, sex partners of HIV-infected persons, men who have sex with men, and heterosexual persons who themselves or whose sex partners have had more than one sex partner since their most recent HIV test.

† The 18 jurisdictions contributing data for the 2006–2009 national HIV incidence estimate were the states of Alabama, Arizona, Colorado, Connecticut, Florida, Indiana, Louisiana, Michigan, Mississippi, New Jersey, New York, North Carolina, South Carolina, Texas, Virginia, and Washington, and the cities of Chicago, Illinois, and Philadelphia, Pennsylvania.

§ As an integral component of NHSS, areas funded for HIV incidence surveillance collect THI, including self-reported date of first positive HIV antibody test, self-reported or documented evidence of negative HIV antibody test, date of most recent negative HIV antibody test, and number of negative HIV tests in the 2 years before testing HIV positive.

¶ Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.

The majority (59%) of the adults and adolescents diagnosed with HIV infection in this analysis had a negative HIV test at some point before HIV diagnosis; only 24% had a negative test within 12 months before HIV diagnosis.

What are the implications for public health practice?

The findings in this report underscore the need to enhance efforts to increase annual HIV testing for populations at high risk for HIV infection to increase early detection, reduce the percentage of persons being diagnosed with HIV on their first test, and reduce the time between onset of HIV infection and its diagnosis. The use of an effective combination of HIV prevention efforts will ensure the greatest impact among persons at high risk for HIV infection.

* Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing risk factor information, but not for incomplete reporting.

† Data used to determine whether a person had a negative HIV test result before HIV diagnosis.

§ Those with a negative HIV test at any point before the first positive HIV test.

¶ The 18 jurisdictions contributing data for the 2006–2009 national HIV incidence estimate were the states of Alabama, Arizona, Colorado, Connecticut, Florida, Indiana, Louisiana, Michigan, Mississippi, New Jersey, New York, North Carolina, South Carolina, Texas, Virginia, and Washington, and the cities of Chicago, Illinois, and Philadelphia, Pennsylvania.

** Percentage among those for whom testing history information was available.

†† Because column totals for estimated numbers were calculated independently of the values for the subpopulations, the values in each column might not sum to the column total.

§§ Hispanics/Latinos might be of any race.

¶¶ Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.

*** Includes hemophilia, blood transfusion, perinatal exposure, and any risk factor not reported or not identified.

TABLE 2. Time from last negative HIV test to HIV diagnosis among adults and adolescents diagnosed with HIV infection* who have HIV testing history information,† by selected characteristics — National HIV Surveillance System, 18 jurisdictions,§ 2006–2009

Characteristic

Persons diagnosed with HIV infection with testing history information

No.

With previous negative HIV test

No previous test

≤12 mos before

13–24 mos before

>24 mos before

No.

(%)¶

No.

(%)¶

No.

(%)¶

No.

(%)

Total**

57,476

13,900

24.2

6,758

11.8

12,094

21.0

23,427

40.8

Age group at diagnosis (yrs)

13–29

21,734

7,122

32.8

3,025

13.9

3,556

16.4

7,513

34.6

30–39

14,816

3,502

23.6

1,838

12.4

3,699

25.0

5,430

36.7

40–49

13,244

2,324

17.5

1,359

10.3

3,292

24.9

5,992

45.2

≥50

7,683

952

12.4

537

7.0

1,546

20.1

4,492

58.5

Race/Ethnicity

Black/African American

29,945

6,649

22.2

3,355

11.2

6,091

20.3

13,188

44.0

Hispanic/Latino††

11,135

2,729

24.5

1,229

11.0

2,295

20.6

4,644

41.7

White

14,781

4,112

27.8

1,969

13.3

3,400

23.0

4,935

33.4

Other

1,616

410

25.4

205

12.7

308

19.1

659

40.8

Transmission category (males)

Male-to-male sexual contact

31,493

9,260

29.4

4,147

13.2

6,224

19.8

11,176

35.5

Injection drug use

3,104

442

14.2

274

8.8

650

20.9

1,674

53.9

Male-to-male sexual contact and injection drug use

1,781

453

25.4

246

13.8

402

22.6

630

35.4

Heterosexual contact§§

6,186

852

13.8

462

7.5

1,273

20.6

3,476

56.2

Other¶¶

48

5

10.3

3

6.2

8

16.5

31

64.0

Subtotal

42,613

11,013

25.8

5,131

12.0

8,557

20.1

16,986

39.9

Transmission category (females)

Injection drug use

2,306

484

21.0

262

11.4

549

23.8

950

41.2

Heterosexual contact§§

12,499

2,399

19.2

1,361

10.9

2,978

23.8

5,451

43.6

Other¶¶

58

5

8.6

3

5.2

9

15.5

40

68.7

Subtotal

14,863

2,887

19.4

1,627

10.9

3,537

23.8

6,441

43.3

Abbreviation: HIV = human immunodeficiency virus.

* Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing risk factor information, but not for incomplete reporting.

† Data used to determine whether a person had a negative HIV test result before HIV diagnosis and to calculate the time from the last negative HIV antibody test to HIV diagnosis.

§ The 18 jurisdictions contributing data for the 2006–2009 national HIV incidence estimate were the states of Alabama, Arizona, Colorado, Connecticut, Florida, Indiana, Louisiana, Michigan, Mississippi, New Jersey, New York, North Carolina, South Carolina, Texas, Virginia, and Washington, and the cities of Chicago, Illinois, and Philadelphia, Pennsylvania.

¶ Percentage among those for whom testing history information was available to calculate the time since their last negative HIV test to HIV diagnosis.

** Because column totals for estimated numbers were calculated independently of the values for the subpopulations, the values in each column might not sum to the column total.

†† Hispanics/Latinos might be of any race.

§§ Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.

¶¶ Includes hemophilia, blood transfusion, perinatal exposure, and any risk factor not reported or not identified.

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